Son calls for closed doors after care home killing

A man whose mother was beaten to death by a fellow dementia patient known to wander at night is calling for a hotel-style door locking system in care homes.

Sheila Hartman, 88, was attacked by 92-year-old Eunice Clarke at Ridgeway Lodge, near Dunstable, Bedfordshire, in October 2022.

An Adult Safeguarding Review into the case said: "We have been conned when it comes to dementia care" and called for better national standards and resources.

HC-ONE, which operates the home, said it was continuing to implement the review's recommendations, while the Department for Health and Social Care said it was committed to "turning around" dementia support.

The two women, who both had advanced dementia, were in rooms on the upper floor, with an empty room between them.

They were said to have got on well, an inquest in 2024 was told.

However, Clarke's condition meant she believed she was in her own home and suffered delusions that staff or residents were intruders, the review found.

She was "often unsettled at night" and sometimes "reported to be in other people's rooms asking them why they were in her house".

Previous episodes of violence and aggression were also recorded by staff, but managers were not made aware.

Hartman's son Richard Uridge told the BBC: "My mum's attacker walked out of her bedroom - the door was wide open as far as we know - turned right and two doors down was my mother's bedroom, also with the door open.

"In her confusion, the other woman thought that my mother was an intruder, so she set about her with her walking stick many, many times around the head and body.

"My mother died of her injuries in hospital six or seven hours later."

He told the review that the subject of bedroom doors had never been raised with him by Ridgeway Lodge staff.

"I'm pretty sure if both bedroom doors had been closed, this wouldn't have happened, he added.

He is urging care homes to install technology similar to hotels, that "allow guests to access their own rooms effortlessly, allow staff to access all rooms yet keep unwanted guests out".

A review into the incident was commissioned by Central Bedfordshire Council. Its author, Dr Sheila Fish, said it appeared that "having her [Hartman's] door open would be typical, making it easier for staff to peek in on passing".

However, that policy "did not consider that she was also sleeping next door but one to [Clarke]".

She added: "There seems to be very little research about social care practice regarding bedroom doors in care homes".

Fish said the tragedy also revealed "a startling picture" and "apparent inertia" nationally around dementia care.

"It brought the analogy of the emperor's new clothes to mind; the notion that we have been conned when it comes to dementia care, ripped off, but no-one is calling it out."

She said a lack of a national dementia strategy or quality standards meant "expectations on [care home] providers are not clear or mandatory".

When it came to Ridgeway Lodge, staff did not have effective training or competency checks.

"There was a lack of dementia expertise to promote a safe and personalised care experience," she added.

More support was also needed to help people seeking care placements for relatives with significant needs.

Fish said the families of both women "had sought a place that could provide their respective mothers with the care and support they needed as their dementia progressed and where they would be kept safe".

"Both women became victims in a breakdown of these arrangements," she added.

Eunice Clarke died some months after the attack.

She had spent her life working for the NHS and was described as "a committed Christian" who "liked spending time with others and singing".

In a statement, her daughter Debbie told BBC News that her illness was responsible for what happened.

"It may have been my mum's body who carried out this horrendous incident, but that was not my mum," she said.

HC-ONE said: "We have made it our mission to ensure that Sheila's legacy is one that certifies the safety and protection of those with advanced dementia living in residential care.

"We welcome this collaborative review, and we are working to ensure that these [recommendations], as well as our learnings from Sheila's story, continue to be implemented across our homes and the wider sector."

A spokesperson for the Department of Health and Social Care said: "This is a shocking case, and our sympathies are with the families affected.

"We know our health and adult social care system has struggled to support those with dementia, and we are committed to turning this around so every person living with the disease receives the high standard of care they need and deserve from diagnosis through to end of life."

It said it would deliver a "Modern Service framework for Frailty and Dementia" to set "clear standards for high quality care".

Do you have a story suggestion for Beds, Herts or Bucks? Contact us below.

Follow Beds, Herts and Bucks news on BBC Sounds, Facebook, Instagram and X.